Failure to Ensure Safe Discharge and Continuity of Care for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that ensured the safety and total care needs of a resident with multiple complex medical and psychosocial issues. The resident, who had diagnoses including alcohol abuse, malnutrition, chronic illnesses, and a history of homelessness, was discharged without evidence of a safe location to go or continuity of care post-discharge. The medical record review showed repeated instances where the resident left the facility unsupervised, often without signing out, and there were no new interventions or care plan updates to address these behaviors or ensure the resident's safety during leaves of absence. Despite the resident's known risk factors, including substance abuse and mental health concerns, there was no documentation of mental health or substance abuse services being offered or provided during the resident's stay. The facility's documentation revealed that the resident frequently left the premises, sometimes being found in unsafe situations such as in the street or at bus stops, and on several occasions required staff or police intervention to return. There was no evidence of comprehensive assessment or follow-up regarding the resident's ability to safely leave the facility, nor was there documentation of communication with the resident's physician or responsible party when the resident left. The care plan for anticipated discharge was not followed, and there was no evidence of social service follow-up or coordination with community resources, even after the resident expressed uncertainty about his housing situation and demonstrated ongoing psychosocial distress. After leaving the facility, the resident was found homeless, malnourished, and expressing suicidal ideation, leading to multiple hospital admissions. Interviews with facility staff confirmed a lack of notification to appropriate authorities or support services when the resident left and did not return. The facility's own investigation was minimal, with no staff or resident statements obtained, and the documentation did not support that the resident had requested to leave against medical advice. The facility's policies regarding leave of absence and discharge were not effectively implemented, and the resident's medical and psychosocial needs were not met at the time of discharge.
Removal Plan
- LNHA and the DON were educated on the facility's discharge against medical advice (AMA) and leave of absence (LOA) policies.
- An audit was completed by LNHA of current residents with plans to discharge to the community to ensure discharge planning was in progress and discharge plans were accurately recorded in each resident's record.
- SSD and LNHA were educated by RDCS on ensuring support for residents' psychosocial well-being and providing assistance with discharge needs and requests.
- SSD will complete new admission care conferences which will include screening assessments such as the PHQ-9 depression screening tool.
- The DON provided education to the facility's interdisciplinary team (IDT) and licensed nurses on the facility's policies on discharge AMA and LOA policies.
- A Quality Assurance Performance Improvement (QAPI) meeting was held, including completion of a root cause analysis of the event and development of a plan of correction.
- MDS Nurse completed an audit of in-house residents with the diagnosis or history of substance abuse or polysubstance abuse.
- The DON provided one-on-one education to residents with a substance abuse or polysubstance abuse history on the facility's leave of absences policy.
- Ad hoc education will be provided on an ongoing basis by RDCS or Regional Nurse for any staff member who is not correctly implementing the AMA and/or LOA policies on an as-needed basis.
- Newly hired nurses will be trained on the facility's discharge AMA and LOA policies upon hire by the DON or designee.
- The DON or designee will provide education to agency staff nurses on the facility's discharge AMA and LOA procedures prior to the agency nurse being able to accept the assignment at the facility.
- LNHA or designee will audit discharges to ensure documentation supports a safe discharge, including a discharge plan that meets the residents' behavioral and psychosocial needs.
- The results of ongoing audits will be reviewed by the facility's QAPI committee to determine if additional audits or education is needed.
- At Utilization Review (UR) meetings, LNHA or designee will discuss upcoming resident discharges and safe discharge planning.